A nurse in a clinic is collecting data from an adolescent who has type 1 diabetes mellitus.Which of the following findings is the priority for the nurse to report?
Client's current blood glucose is 220 mg/dL
Client is exhibiting Kussmaul respirations
Client reports vomiting once that day
Client reports frequent urination
The Correct Answer is B
Choice A reason:
A blood glucose level of 220 mg/dL is elevated and should be addressed, but it may not be an immediate priority compared to the presence of Kussmaul respirations.
Choice B reason.
Correct. Kussmaul respirations are a sign of diabetic ketoacidosis (DKA), a severe complication of diabetes. This requires immediate attention and intervention.
Choice C reason:
Vomiting is a concerning symptom, but it may not be as immediately life-threatening as Kussmaul respirations.
Choice D reason:
Frequent urination is a common symptom of diabetes, but it may not require immediate intervention unless it is accompanied by other severe symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Fasting is not typically required for an EEG, so this instruction is not necessary.
Choice B reason:
Washing the hair is important before an EEG, as it helps to remove any oils or substances that might interfere with the electrodes' ability to record brain activity.
Choice C reason:
A mild sedative is not a standard part of an EEG procedure.
Choice D reason:
Having a full bladder is not necessary for an EEG.
Correct Answer is A
Explanation
Choice A reason:
At 18 months, a toddler should typically be saying more than four words. This finding may
indicate a potential delay in speech development, and it should be reported to the provider for further evaluation.
Choice B reason:
Building a tower of three blocks is an appropriate developmental milestone for an 18-month-old and does not warrant reporting.
Choice C reason:
Temper tantrums are a normal behavior for toddlers, as they are still developing emotional regulation skills. This finding does not require reporting unless it is severe or causing harm to the child.
Choice D reason:
Jumping in place with both feet is an appropriate developmental milestone for an 18-month-old and does not warrant reporting.
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